Each year, approximately 1.5 million Americans seek medical/psychiatric treatment for alcoholism. Alcoholism remains one of the major causes of nutritional deficiency syndromes in the United States. Alcohol (ethanol) is directly toxic to many tissues and can affect almost every cell and organ system in the human body. Additionally, chronic use leads to impaired absorption, transport, and storage of numerous vitamins and minerals (Persson J., Scandinavian Journal of Gastroenterology, 1991;26: pp. 3-15.). Further, the nutritional content of ethanol is very poor and is often consumed in the context of inadequate dietary intake. For example, on average Americans consume about 4.5% of total calories as alcohol while alcoholics may consume 50% of their daily calories as ethanol (Feinman L., Lieber C. S. in: Medical and Nutritional Complications of Alcoholism: Mechanisms of Management. (Ed. Lieber, C. S.), 1992 Plenum Medical Book Company, New York, pp. 515-530.). The exact reasons for poor food intake among alcoholics are unknown but may include depressed consciousness during intoxication, hangover, and gastrointestinal problems induced by ethanol consumption.
Vitamins
Serious medical complications may occur as a result of uncorrected malnutrition. Most notably, as a result of thiamine (Vitamin B.sub.1) deficiency, Wernicke's syndrome, an encephalopathy marked by gait disturbance, acute confusion, memory loss and disorientation may develop in chronic users of ethanol. If untreated with thiamine supplementation, this condition may progress to the more serious Korsakoffs syndrome, a permanent disorder leading to brain damage in which patients manifest symptoms such as psychosis, severe memory loss, delirium, insomnia, and painful extremities. These patients frequently require long-term institutionalization. Additionally, beriberi heart disease and possibly polyneuropathy may result from thiamine deficiency. Alcoholics have demonstrated impaired abilities to absorb thiamine (Holzbach E. Journal of Studies on Alcohol, 1996;57: pp. 581-584.). However, it is clinically impractical to measure thiamine blood concentrations. Thiamine corrects early Wernicke signs rapidly and may prevent development of an irreversible Korsakoff dementia. Once the dementia is established, thiamine usually does not help. Therefore, due to the relative safety and ease of administering thiamine, 50-100 mg is generally given orally as a separate drug entity to [all] alcoholics daily while in treatment.
A significant number of alcoholics suffer from anemia, a general term for describing a reduction in the number of circulating red blood cells (erythrocytes). The clinical expression of anemia results from tissue hypoxia or oxygen starvation and the resulting cardiovascular pulmonary compensatory responses. Severe anemia is associated with weakness, vertigo, headache, tinnitus, fatigue, drowsiness, irritability, and in some cases bizarre behavior. Additionally, amenorrhea, loss of libido, GI complaints, and splenomegaly can result. Finally, heart failure and shock may result in some patients. Specifically, megaloblastic anemia, a disorder in the body's ability to manufacture functional red blood cells (erythropoiesis) may occur in a large number of alcoholics as a result of depleted B-complex vitamins such as folic acid and/or cyanocobalamin (Vitamin B.sub.12). Alcoholics tend to have low folic acid status when they are drinking. Ethanol is also known to accelerate the production of megaloblastic anemia in patients with depleted folic acid stores. In addition to folic acid deficiency, the direct effect of ethanol on bone marrow, liver disease, bleeding, iron deficiency, and infection may exert additive influences on the hematological status of the alcoholic. For this reason, chronic ethanol users are commonly administered 1 mg of folic acid by mouth daily as a separate drug entity while in treatment to replete folic acid stores.
When there is a general poor intake of B-vitamins, riboflavin (Vitamin B.sub.2) deficiency may result, and this has been found to be the case with alcoholics (Cook C. C. H, Thomson A. D. British Journal of Hospital Medicine, 1997;57: pp.461-465.). Clinical consequences of riboflavin deficiency include behavioral changes and peripheral neuropathy. For this reason, riboflavin is commonly administered to alcoholics daily as a component (1-3 mg) of a multivitamin as long as they are in treatment.
Behavioral changes, neurological disorders, peripheral neuropathy and dermatological disorders can result in part due to pyridoxine (Vitamin B.sub.6) deficiency disorders. This is most important with regard to alcoholics since up to 50% may have pyridoxine deficiencies as measured in plasma. It is unknown if inadequate dietary intake alone accounts for the deficiency, but increased destruction and reduced formation of pyridoxine may be related to ethanol use. Whatever the cause, clinical management usually involves provision of pyridoxine (1-3 mg) as part of a daily multivitamin administered as long as the patient is in treatment.
The absorption of cyanocobalamin (Vitamin B.sub.12) has also been shown to be decreased when coadministered with ethanol. Deficiencies may result in hematological as well as neurological disorders. Cyanocobalamin (6-12 mg) is commonly administered as part of a multivitamin supplement on a daily basis to alcoholics in treatment.
Biotin is a coenzyme that is essential to the metabolism of both fatty acids and carbohydrates. Deficiency states may result in dermatological disorders. Biotin 10-50 mcg is commonly included in multivitamin supplements used in the treatment of malnourished individuals.
Niacin (Nicotinic acid) deficiency may develop as a result of poor dietary intake among alcoholics. This water soluble vitamin is found in many of the same foods which contain thiamine. Severe niacin deficiency may result in the clinical condition of Pellagra which is characterized by dermatologic, central nervous system, and gastrointestinal symptoms. Niacin is generally included as part of a multivitamin preparation in doses of 10-50 mg given daily.
Clearly, alcoholics have illness related to abnormalities of vitamin D (cholecalciferol) and calcium. They have decreases in bone density and bone mass and increased susceptibility to bone fractures. Decreased blood calcium, phosphorous, magnesium and 25-OH-vitamin D have been reported. Changes in vitamin D metabolism may result from the inability of the alcoholic to hydroxylate vitamin D3 at the 25 position to its more active form. This condition may be in part due to poor liver function, decreased exposure to sunlight, a diet deficient in vitamin D, and malabsorption of fat. The end result may be osteomalacia leading to bone pain and fractures. Since poor dietary intake is common in alcoholics, vitamin D 200-500 IU administered as part of a multivitamin on a daily basis may be prudent.
Vitamin E and selenium serve protective roles as antioxidants and function synergistically in the human body. For instance, vitamin E reduces selenium requirements, prevents its loss from the body, and maintains it in its active form. Conversely, selenium spares vitamin E and reduces the requirement for the vitamin. Alcoholic patients and patients with poor fat absorption may become deficient in vitamin E. Clinical manifestations of vitamin E deficiency include decreased erythrocyte survival, and neurological disturbances including visual problems. Vitamin E 10-50 IU as a component of multivitamin supplements should be administered daily.
Trace Elements
There are 13 trace elements presently recognized as necessary for normal biological functioning of the human body. They are referred to as trace elements as they occur in concentrations &lt;0.005% body weight. In order of demonstrated need they are iron, iodine, copper, manganese, zinc, cobalt, molybdenum, selenium, chromium, fluorine, silicon, nickel, and arsenic (The Merck Manual, 15th Edition (1987) pp. 894-1013). Importantly, a variety of essential trace elements such as magnesium, zinc, and selenium are often found in inadequate amounts in chronic alcoholics (Cook C. C. H., Walden R. J., Graham B. R., Gillham C., Davies S., Prichard B. N. C. Alcohol & Alcoholism, 1991;26: pp. 541-548.).
Serum selenium levels have been found to be decreased in the alcoholic, especially in the presence of liver disease. Selenium should be supplemented if patients are suspected to be deficient in this element. Muscle pain and tenderness have been reported to result from deficiency states. Selenium may be administered at doses from 5-50 mcg daily. However, at present, no U.S. Recommended Daily Allowance (RDA) has been established.
Chronic alcoholism is clearly associated with magnesium deficiency as measured by serum levels of the element. Alcohol ingestion is known to cause magnesium excretion. Magnesium deficiency may lead to hypocalcemia and hypoparathyroidism and clinical manifestations may include lethargy, weakness, anorexia nausea. If magnesium deficiency is suspected or confirmed, repletion is indicated. This may be done by giving the element intramuscularly or by oral supplementation. Magnesiun 100-400 mg may be given orally as a supplement daily.
As a consequence of the known risk of malnutrition in this patient population, most physicians who treat alcoholic patients in the inpatient hospital settings tend to treat alcoholics with three (3) immediate release oral supplement products, a multivitamin, thiamine 100 mg, and folic acid 1 mg. Additionally, some patients are also treated with thiamine and magnesium sulfate intramuscularly on admission.
At present there is no existing single entity product to administer to patients which is an extended-release multivitamin with minerals and trace elements in the aforementioned dose ranges and which specifically contains thiamine and folic acid in the desired amounts of 100 mg and 1 mg, respectively. Umbdenstock (U.S. Pat. No. 5,308,627) described a nutritional product to assist persons recovering from addictions to various health damaging substances. The product did not have folic acid in the appropriate amount (1 mg), and 3 tablets would have to be administered to approach 100 mg of thiamine. Additionally, the Umbdenstock product contains valerian, an herbal product of questionable utility, sedating effects, and unlikely to be recommended by most physicians treating alcoholic patients. Lastly, the product was not an extended release formulation.